For your convenience, below are important forms and documents to help you easily manage your health coverage.
- Notice of Privacy Practices describes how medical information about you may be used and disclosed and how you can get access to this information.
- HIPAA Privacy Practices and Forms contains privacy information and documentation related to the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
Claim reimbursement forms
As a member of Keystone 65 HMO or Personal Choice 65SM PPO, you are covered for an influenza vaccine each year. If you received your vaccine at a non-participating provider and paid out of pocket, you can use the following forms to apply for reimbursement.
- Keystone 65 HMO Influenza Vaccine Reimbursement Form
- Personal Choice 65SM PPO Influenza Vaccine Reimbursement Form
To request a reimbursement as a Personal Choice 65 PPO Member for a out-of-network claim, please complete the non-network claim form and submit to the Independence Blue Cross Claims Department at the address listed on the form.
Cataract glasses claim
To request a reimbursement for a cataract glasses purchase, please complete the Cataract Glasses Reimbursement Form and submit to the Independence Blue Cross Claims Department at the address listed on the form.
Summary of Benefits
2022 Summary of Benefits
- Keystone 65 Basic HMO, Keystone 65 Focus HMO, Keystone 65 Select HMO Summary of Benefits
- Keystone 65 Preferred HMO Summary of Benefits
- Personal Choice 65 PPO Summary of Benefits
Call us at 1-877-393-6733 (711 for the speech- and hearing-impaired), 8 a.m. to 8 p.m., seven days a week. However, please note that on weekends and holidays from March 31 through September 30, your call may be sent to voicemail.
Extra help is available for those who need it most. Find out whether you qualify for low-income subsidy.
Evidence of Coverage and Outline of Coverage
The Evidence of Coverage (EOC) is a comprehensive resource guide to your health care coverage. It explains your benefits, premiums, and cost-sharing; conditions and limitations of coverage; and plan rules.
After you've joined the plan, you will receive the Evidence of Coverage in the mail. This is a legal document that should be kept in a safe place.
2022 Evidences of Coverage
- Keystone 65 Medical-Only HMO Evidence of Coverage
- Keystone 65 Rx HMO Evidence of Coverage
- Personal Choice 65SM Medical-Only PPO Evidence of Coverage
- Personal Choice 65SM Rx PPO Evidence of Coverage
MedigapFreedom, MedigapSecurity, and Security 65 Outlines of Coverage
- MedigapFreedom Individual Outline of Coverage
- MedigapFreedom Individual Private Exchange Outline of Coverage
- MedigapFreedom Group Outline of Coverage
- MedigapSecurity Group Outline of Coverage
Use a Change Form to move from one plan to another plan. For example, you can use a Change Form to move from Keystone 65 Preferred HMO to Keystone 65 Select HMO or Personal Choice 65 Medical-only PPO to Personal Choice 65 Rx PPO. This change can only occur during a valid Election Period.
Please keep in mind that you cannot use a change form to switch between Personal Choice 65SM PPO, a Blue Cross Medicare Advantage PPO Plan from QCC Insurance Company to Keystone 65 HMO, a Blue Cross Medicare Advantage HMO Plan from Keystone Health Plan East.
2022 Change Forms
2022 Keystone 65 HMO
Keystone 65 HMO
PO Box 7799
Philadelphia PA 19101-7799
2022 Personal Choice 65
Personal Choice 65 PPO
PO Box 7799
Philadelphia PA 19101-7799
Online Plan Changes
To complete a Keystone 65 HMO or Personal Choice PPO plan change online:
- Visit the iQuote online tool
- Select Enroll Now
- Enter birthdate, zip code, county, and coverage start date
- Select Add to cart on the desired plan
- Select the plan in your cart, and select apply now
- Select yes when asked if you are a current IBX plan member
- Enter Member ID, first and last name and select continue
- Complete the enrollment form
Annual Notice of Changes
2022 Annual Notice of Changes
- Keystone 65 Basic Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Basic Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Focus Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Focus Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Preferred Medical-Only HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Preferred Medical-Only HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Preferred Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Preferred Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Select Medical-Only HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Select Medical-Only HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 Select Rx HMO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Keystone 65 Select Rx HMO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Medical-Only PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Prime Rx PPO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Personal Choice 65 Prime Rx PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Personal Choice 65 Rx PPO Annual Notice of Changes (Chester, Delaware, Montgomery Counties)
- Personal Choice 65 Rx PPO Annual Notice of Changes (Philadelphia, Bucks Counties)
- Keystone 65 HMO Electronic Funds Transfer (EFT) Form
- Personal Choice 65 PPO Electronic Funds Transfer (EFT) Form
- Select Option PDP Electronic Funds Transfer (EFT) Form
If you’d like to switch or leave your current health plan, below are the disenrollment forms available to you. Not all plan changes require a form, and there are only certain times of year that you can switch plans throughout the year. Please read these important instructions regarding requesting disenrollment from the plan.
Medicare Advantage disenrollments
When can I make changes to my Medicare coverage?
- Annual Enrollment Period (AEP) from October 15 through December 7 each year: Anyone can make any type of change for the following year including adding or dropping Medicare prescription drug coverage or changing to a new Medicare Advantage plan. The effective date for the newly selected plan is January 1 of the following year.
- Open Enrollment Period (OEP) from January 1 through March 31 each year: Anyone enrolled in a Medicare Advantage plan (except for a Medicare Medical Savings Account/MSA) has an opportunity to enroll in a different Medicare Advantage plan or disenroll from their Medicare Advantage plan and return to Original Medicare. The effective date of the disenrollment from the MA plan is the first day of the month following the date the disenrollment request is received. Disenrollment requests received by MA organization in January are effective February 1; those received in February are effective March 1; and those received in March are effective April 1. The OEP does not provide an opportunity for those enrolled in Original Medicare to enroll in a Medicare Advantage plan, nor does it allow for Part D changes for individuals enrolled in Original Medicare, including those enrolled in stand-alone Part D plans.
- Special Exceptions: You are unable to make changes at other times of the year, unless you meet certain special exceptions, such as moving out of the plan's service area, joining a plan in your area with a 5-star rating, or qualifying for extra help with your prescription drug costs. If you qualify for extra help with your prescription drug costs you may enroll in, or disenroll from, a plan at any time. If you lose this extra help during the year, your opportunity to make a change continues for two months after you are notified that you no longer qualify for extra help.
Extra help in paying for your insurance plan
People with limited incomes may qualify for extra help to pay for their prescription drug costs. If you qualify, Medicare could pay for 75% or more of your drug costs including monthly prescription drug premiums, annual deductibles, and co-insurance. Additionally, those who qualify won't have a coverage gap or a late enrollment penalty. Many people qualify for these savings and don't even know it. For more information about this extra help, contact your local Social Security office, or call Social Security at 1-800-772-1213. TTY users should call 1-800-325-0778. You can also apply for extra help online at www.socialsecurity.gov/prescriptionhelp.
Learn more about money saving programs.
When should I fill out the disenrollment request form?
You should fill out the appropriate disenrollment form during a valid election period, if you want to change to Original Medicare only and do not want Medicare prescription drug coverage.
You shouldn't fill out the appropriate disenrollment form if you are planning to enroll, or have enrolled, in another Medicare Advantage plan or other Medicare health plan. Enrolling in another Medicare plan will automatically disenroll you from our plan.
You shouldn't fill out the appropriate disenrollment form if you are enrolling in a Medicare prescription drug plan. Enrolling in a Medicare prescription drug plan will automatically disenroll you from the plan to Original Medicare.
Until your disenrollment date, you must keep using the plan's doctors. To avoid any unexpected expenses, you may want to contact us to make sure you've been disenrolled before you seek medical services outside of the plan's network.
How do I submit the disenrollment request?
If you want Original Medicare, as described above, you may fill out the appropriate disenrollment form during a valid election period, sign it, and send it back to us at:
Independence Blue Cross
P.O. Box 7330
Philadelphia, PA 19101-8957
You can also fax the form with a readable signature and date to us at 1-215-241-2275.
Medicare Advantage disenrollment forms
- Keystone 65 Basic Rx HMO Disenrollment Form
- Keystone 65 Focus Rx HMO-POS Disenrollment Form
- Keystone 65 Select Medical-only HMO Disenrollment Form
- Keystone 65 Select Rx HMO Disenrollment Form
- Keystone 65 Preferred Medical-only HMO Disenrollment Form
- Keystone 65 Preferred Rx HMO Disenrollment Form
- Personal Choice 65SM Medical-only PPO Disenrollment Form
- Personal Choice 65SM Rx PPO Disenrollment Form
- Personal Choice 65SM Prime Rx PPO Disenrollment Form
- Personal Choice 65SM Elite Rx Disenrollment Form
- Personal Choice 65SM Saver Rx Disenrollment Form
What are my Medigap rights?
If you will be changing to Original Medicare, you might have a special temporary right to buy a Medigap policy, also known as Medicare supplemental insurance, even if you have health problems. For example, if you are age 65 or older and you enrolled in Medicare Part B within the past 6 months or if you move out of the service area, you may have this special right.
Federal law requires the protections described above. Your state may have laws that provide more Medigap protections. If you have questions about Medigap or Medigap rights in your state, you should contact your State Health Insurance Program, Medicare Education and Decision Insight, or PA MEDI, at 1-800-783-7067. You can also call 1-800-MEDICARE (1-800-633-4227) anytime, 24 hours a day, 7 days a week for more information about trial periods. TTY users should call 1-877-486-2048.
If you need any help, please contact the Member Help Team.
Medicare Supplement (Medigap) disenrollments
Please complete the following form to cancel Security 65 or MedigapSecurity plan coverage. Once you have completed and signed the form, please mail or fax to:
Independence Blue Cross
P. O. Box 13713
Philadelphia, PA 19101-3713
Cancellation Request Forms (without Estate)
Cancellation Request Forms (with Estate)
How to appoint a representative
You may designate someone, such as a relative, friend, lawyer, or anyone else, to file an appeal or grievance on your behalf. This is known as assigning an appointed representative. To do this you must:
- Download the Appointment of Representative Form. It can also be found on CMS's website
- Fill out the form. Both you and the person you are assigning to represent you must sign and date it.
- Send the form back to us at the address below:
Medicare Appeals Unit
P.O. Box 13652
Philadelphia, PA 19101-3652
You can call the Member Help Team to learn how to name your appointed representative or for assistance with filling out the form.
Benefits during disasters
In the event of a Presidential emergency declaration, a Presidential (major) disaster declaration, a declaration of emergency or disaster by a Governor, or an announcement of a public health emergency by the Secretary of Health and Human Services, but absent, or prior to the issuance of, a section 1135 waiver by the Secretary, Independence Blue Cross will:
- Allow beneficiaries to seek care at specified non-contracted facilities (note that Part A and Part B benefits must be furnished at Medicare certified facilities);
- Waive in full, requirements for referrals where applicable;
- Pay out of network claims, or claims where prior authorization/referrals were not obtained at the in-network benefit level;
- Allow members to seek care from non-network providers at the in-network benefit level;
- Waive the 30-day notification requirement to enrollees as long as all the changes (such as reduction of cost-sharing and waiving authorization) benefit the enrollee and;
- Lift refill-too-soon edits for Part D prescription drugs;
Typically, the source that declared the disaster will clarify when the disaster or emergency is over. If, however, the disaster or emergency timeframe has not been closed 30 days from the initial declaration, and if CMS has not indicated an end date to the disaster or emergency, Independence Blue Cross will resume normal operations 30 days from the initial declaration.
Non-discrimination Notice and Multi-Language Insert
Our Medicare Advantage plans have been rated among the nation's best by the Centers for Medicare and Medicaid Services (CMS) 2022 Star Ratings.
Our Keystone 65 HMO plans are the only Medicare Advantage HMO plans in our service area to earn 5 out of 5 stars, and Personal Choice 65SM PPO plans received 4.5 out of 5 stars, CMS’s second-highest rating.
What is the CMS Star Rating System?
The CMS Star Rating System is designed to improve health care quality and control health care costs. The ratings provide a scorecard on overall plan quality, as well as:
- Members’ compliance with preventive care and screening recommendations
- Chronic condition management
- Customer service
- Access to care
How does the CMS Star Rating System benefit our members?
Our 2022 CMS Star Ratings reflect our ongoing commitment to put our members first. Independence Blue Cross is committed to providing high‐quality Medicare Advantage plans and prescription drug coverage that meets or exceeds all CMS quality benchmarks. To achieve this, we focus on many member initiatives including:
- Early detection and prevention measures
- Better customer service
- Support with chronic condition management
- Greater access to care
CMS rewards plans that perform well through increased funding to improve their plans. Examples of these product improvements include:
- Providing more robust supplemental benefits
- Reducing premiums
- Decreasing member cost-share
The CMS Star Ratings system rates all health and prescription drug plans each year based on their quality and performance. Medicare Star Ratings help you know how well our plan is doing. You can use these Star Ratings to compare our plan's performance to other plans.
Website last updated: 12/13/2021